What is prior authorization?
For some medical services and equipment, you must get permission from the Ohio Department of Medicaid, the Ohio Department of Developmental Disabilities, or a managed care plan before they will pay for it. “Prior authorization” is the way you ask for permission.
When do I need to request prior authorization?
There are many types of medical services and equipment that require prior authorization. This is not a complete list, but some examples are:
- Some home health services and private duty nursing services
- Some durable medical equipment, such as wheelchairs, speech-generating devices, hearing aids, orthopedic shoes, compression garments, hospital beds, and some repairs to previously purchased equipment
- Some brand name prescriptions
- Dentures and braces
- Specialty optical items, including contact lenses, tinted lenses, prosthetic eyes, and low-vision aids
- Services for children under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program (known as Healthchek in Ohio) that are more than the amount of services that adults can receive, such as speech therapy or physical therapy
- Some mental health services
- Some surgical procedures, including organ, bone marrow, or stem cell transplants
- Funding for Individual Options Waiver services that is more than the person’s funding range
If you do not know whether a service or equipment requires prior authorization, you or your medical provider should contact the Ohio Department of Medicaid or your managed care plan. Managed care plans often require prior authorization for additional services or equipment, such as home health services. Your member handbook or your managed care plan can tell you which services or equipment require prior authorization.
How do I request prior authorization?
If you need services or equipment that require prior authorization, the doctor or medical provider who wants you to have that service or equipment will send in the request. You should work with your provider to make sure they have all of the information they need to make the prior authorization request.
Is the prior authorization process the same for requests for additional Individual Options Waiver funding?
No, the process is different. An individual’s yearly funding range for Individual Options (IO) Waiver services is determined by the Ohio Developmental Disabilities Profile (ODDP). For some people, the ODDP funding range is not high enough. Requests for more funding must be made to the county board of developmental disabilities. The county board will prepare the prior authorization request and send it to the Ohio Department of Developmental Disabilities (DODD). DODD will look over the request, decide whether to approve or deny it, and then notify you.
How will I know if my prior authorization request has been approved or denied?
If the prior authorization request is approved, then your provider will be notified that they can go ahead and give you the service or equipment. If the Ohio Department of Medicaid or your managed care plan needs more information before they can approve or deny the request, then your provider will be notified that they need to submit additional information.
If the prior authorization request is denied, you will receive a notice. The notice will tell you that the request has been denied, the reason it was denied, and how you can appeal if you disagree. The appeal process you should use depends on whether the decision was made by a managed care plan or a different agency. Your denial notice will explain how to appeal and the timeline for asking for an appeal. See DRO’s FAQs on Medicaid Appeals for more information.